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Hip Osteoarthritis

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Other Names

  • Osteoarthritis of the Hip
  • Hip OA
  • DJD of the Hip
  • Degenerative Joint Disease of the Hip

Background

  • This page refers to Hip Osteoarthritis (Hip OA)

History

Epidemiology

  • Prevalence
    • Jordan et al: symptomatic hip OA was reported at 9.2% among adults age 45 years and older, with 27% of the study population having radiographic evidence of disease[1]
    • Men have higher prevalence before age 50, women have higher prevalence after age 50
    • Highest in Caucasians (3-6%), estimated to be <1% in Asians, blacks, East Indians, or native Americans[2]
  • Incidence
    • Estimated at 88 per 100,000 person years (need citation)
  • CDC: Lifetime risk for symptomatic hip OA is 18.5% (men), 28.6% (women)[3]

Pathophysiology

Etiology

  • Primary OA
    • Accounts for majority of hip OA
    • Idiopathic process
    • Not characterized by inflammatory process, rise in systemic inflammatory markers
    • Combination of genetic, age-related changes, mechanical stress and biomechanical factors
  • Secondary OA
  • Degenerative process
    • Characterized by progress loss of articular cartilage, mismatch between damage and repair
    • Cartilage damage occurs as a combination of biomechanical forces, biochemical factors
    • Subsequent reactive bone formation, osteophyte growth, bone remodeling
    • Para-articular tissues also involved
    • Hip OA results as a constellation of all these factors

Associated Conditions

Pathoanatomy

  • Hip Joint
  • Hyaline Cartilage
    • Composed of chondrocytes embedded in extracellular matrix
    • Extracellular matrix composed of proteoglycans, including aggrecan, type II collagen

Risk Factors

Differential Diagnosis

Clinical Features

  • History
    • Patient course is most commonly insidious, worsening over time
    • Pain is in the hip or groin
    • Worse in the morning or after long periods of rest
    • Stiffness, which is often transient
    • Movement and activities that mobilize the joint may provide relief
    • Ask patient "do you have trouble putting on socks and shoes"?
  • Physical Exam: Physical Exam Hip
    • May see restriction and pain with internal and external rotation
    • Limited extension, flexion, internal rotation
  • Special tests

Evaluation

  • Moderate-Severe OA of right hip

    Moderate-Severe OA of right hip

  • Severe bilateral hip OA

    Severe bilateral hip OA

Radiographs

  • Standard Radiographs Hip
  • Findings
    • Joint space narrowing, which can be obliterated in end-stage disease
    • Osteophytes
    • Subchondral sclerosis
    • Subchondral cysts
    • Deformity of femoral head, acetabulum
  • Helpful to trend radiographs over time to monitor disease progression[10]
  • Altman et al: most sensitive diagnostic criteria is hip pain with two of the following[11]
    • ESR <20 mm/hr (not routinely tested)
    • Femoral or acetabular osteophytes
    • Joint space narrowing

CT

  • Not required for diagnosis
  • May be indicated for pre-op planning or to exclude other etiologies
  • Helpful to get a better sense of bone structures and articular surface

MRI

  • Not required for diagnosis
  • May be indicated for pre-op planning or to exclude other etiologies
  • Helpful to evaluate the Acetabular Labrum, periarticular strucctures

Laboratory Evaluation

  • Generally not indicated unless secondary cause is implicated
  • Takahash et al: correlation between serum pyridinoline and tissue inhibitor of metalloproteinases 1 (TIMP-1) levels and the severity of OA assessed by the KL System[12]
    • Not commercially available but suggest future diagnostic and prognostic markers

Classification

Kellgren-Lawrence Classification

  • Grade 1[13]
    • Doubtful OA with possible joint space narrowing medially
    • Subtle osteophyte formation around the femoral head
  • Grade 2
    • Mild OA with definite joint space narrowing inferiorly
    • Definite osteophyte formation, slight subchondral sclerosis
  • Grade 3
    • Moderate OA with marked narrowing of the joint space
    • Small osteophytes, some sclerosis and cyst formation
    • Deformity of the femoral head and acetabulum
  • Grade 4
    • Obliterated joint space with features seen in grades 1 to 3, large osteophytes
    • Gross deformity of the femoral head and acetabulum

Tonnis Classification

  • Grade 0
    • Normal radiographs
  • Grade 1
    • Sclerosis of femoral head and acetabulum
    • Slight joint space narrowing
    • Slight lipping at joint margins
  • Grade 2
    • Small cysts in femoral head/acetabulum
    • Moderate joint space narrowing
    • Moderate loss of head sphericity
  • Grade 3
    • Large cysts in femoral head/acetabulum
    • Joint space obliteration/severe narrowing
    • Severe femoral head deformity vs. AVN

Management

Prognosis

Nonoperative

General

  • Patient Education
    • Helping patient understand disease process, empower them in their own care
    • Shown to decrease pain, improve quality of life in patients affected by OA[14]
  • Physical Exercise
    • Low-impact exercise is associated with reduction in pain[15]
    • Consider water-based or aquatic exercise therapy, which is also beneficial with less weight bearing[16]
    • Avoid exercises/ activities that provoke pain such as twisting, high impact sports (running)
    • Promote low impact activities such as yoga, cycling, swimming
    • Promote improved flexibility, stretching and range of motion
  • Physical Therapy
    • First line therapy for mild-moderate hip OA[17]
    • In patients with moderate-severe disease, PT is much less likely to be helpful
  • Weight Reduction
    • 10 lbs of weight gain is equivalent to 60 lbs of stress on the joint[18]
    • Weight loss is associated with reduction in cartilage loss, joint impact
  • Foot wear
    • Patients should be educated, encouraged to wear shoes with good shock absorbance, arch support
  • Assist Devices should be considered including
    • Walking sticks
    • Tap turners
    • Walking cane
    • Rolling walker

Pharmacologic Therapies

  • Acetaminophen
    • Literature is not great for acetaminophen[19], often used in conjunction with NSAIDS
  • NSAIDS
    • Consider oral, topical
  • Capsaicin
    • Limited use due to joint depth
  • Opioids
    • Indicated in refractory cases, not first line therapy
  • Glucosamine, Chondroitin
    • Some benefit in reducing pain, no beneficial effects on function from knee OA literature
    • Evidence is underwhelming[20]
  • Needs to be updated/ researched

Modalities

Joint Injections

Operative

  • Indications
    • Severe/ Kellgren grade 4
    • Refractory to conservative measures
  • Technique
    • Total Hip Arthroplasty (THA)
    • Hip Resurfacing
    • Arthroscopic Debridement (controversial)
    • Osteotomy
    • Femoral head resection

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play

  • Needs to be updated

Complications

  • Increased fall risk[22]
  • Chronic pain
  • Loss of function
  • Inability to return to work or sport

See Also

References

  1. ↑ Jordan JM, Helmick CG, Renner JB, et al. Prevalence of hip symptoms and radiographic and symptomatic hip osteoarthritis in African Americans and Caucasians: the Johnston County Osteoarthritis Project. J Rheumatol. 2009;36(4):809-815.
  2. ↑ 2.0 2.1 Brandt, Kenneth D., Paul Dieppe, and Eric L. Radin. "Etiopathogenesis of osteoarthritis." Rheumatic Disease Clinics of North America 34.3 (2008): 531-559.
  3. ↑ Murphy NJ, Eyles JP, Hunter DJ. Hip osteoarthritis: Etiopathogenesis and implications for management. Adv Ther. 2016 Nov;33(11):1921–46. DOI:
  4. ↑ Ganz, R, Leunig, M, Leunig-Ganz, K, Harris, WH. The etiology of osteoarthritis of the hip. Clin Orthop Relat Res. 2008;466(2):264-272.
  5. ↑ Felson DT. Epidemiology of hip and knee osteoarthritis. Epidemiol Rev. 1988;10:1–28. DOI:
  6. ↑ MacGregor AJ, Antoniades L, Matson M, Andrew T, Spector TD. The genetic contribution to radiographic hip osteoarthritis in women: Results of a classic twin study. Arthritis Rheum. 2000 Nov;43(11):2410–6. DOI:
  7. ↑ Harris EC, Coggon D. Hip osteoarthritis and work. Best Pract Res Clin Rheumatol. 2015 Jun;29(3):462–82.
  8. ↑ Kujala UM, Kaprio J, Sarna S. Osteoarthritis of weight bearing joints of lower limbs in former élite male athletes. BMJ. 1994 Jan 22;308(6923):231–4. DOI: https://doi.org/10.1136/bmj.308.6923.231. Erratum in: BMJ 1994 Mar 26;308(6932):819.
  9. ↑ Lanyon P, Muir K, Doherty S, Doherty M. Assessment of a genetic contribution to osteoarthritis of the hip: Sibling study. BMJ. 2000 Nov 11;321(7270):1179–83. DOI:
  10. ↑ Reijman M, Hazes JM, Pols HA, et al. Role of radiography in predicting progression of osteoarthritis of the hip: prospective cohort study. BMJ 2005;330:1183.
  11. ↑ Altman R, Alarcón G, Appelrouth D, et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum 1991;34:505-14.
  12. ↑ Takahashi M, Naito K, Abe M, et al. Relationship between radiographic grading of osteoarthritis and the biochemical markers for arthritis in knee osteoarthritis. Arthritis Res Ther 2004;6:R208-12.
  13. ↑ Kellgren J. The Epidemiology of Chronic Rheumatism. Vol. 2. Oxford: Blackwell Scientific; 1963. Atlas of standard radiographs in arthritis.
  14. ↑ Hochberg MC, Altman RD, Brandt KD, et al. Guidelines for the medical management of osteoarthritis. Part I. Osteoarthritis of the hip.American College of Rheumatology. Arthritis Rheum 1995;38:1535-40.
  15. ↑ Fransen M, McConnell S, Hernandez-Molina G, Reichenbach S. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. 2014 Apr 22;(4):CD007912. DOI:
  16. ↑ Bartels E, Juhl C, Christensen R, Hagen K, Danneskiold-Samsøe B, Dagfinrud H, Lund H. Aquatic exercise for the treatment of knee and hip osteoarthritis. 2016 Mar 23;3:CD005523. DOI:
  17. ↑ Zhang W, Doherty M, Arden N, et al. EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT) EULAR evidence based recommendations for the management of hip osteoarthritis: Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT) Ann Rheum Dis. 2005 May;64(5):669–81.
  18. ↑ Reyes C, Leyland KM, Peat G, Cooper C, Arden NK, Prieto-Alhambra D. Association between overweight and obesity and risk of clinically diagnosed knee, hip, and hand osteoarthritis: A population-based cohort study. Arthritis Rheumatol. 2016 Aug;68(8):1869–75.
  19. ↑ Ennis, Zandra Nymand, et al. "Acetaminophen for chronic pain: a systematic review on efficacy." Basic & clinical pharmacology & toxicology 118.3 (2016): 184-189.
  20. ↑ Wandel S, et al. Effects of glucosamine, chondroitin, or placebo in patients with osteoarthritis of hip or knee: network meta-analysis. BMJ. (2010)
  21. ↑ He, Wei-wei, et al. "Efficacy and safety of intraarticular hyaluronic acid and corticosteroid for knee osteoarthritis: A meta-analysis." International Journal of Surgery 39 (2017): 95-103.
  22. ↑ ] S.G. Leveille, J. Bean, K. Bandeen-Roche, R. Jones, M. Hochberg, J.M. Guralnik, Musculoskeletal pain and risk for falls in older disabled women living in the community, J. Am. Geriatr. Soc. 50 (2002) 671–678.
Created by:
John Kiel on 5 July 2019 08:33:10
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Last edited:
5 October 2022 13:05:44
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